International Journal of Advanced and Integrated Medical Sciences

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Psychiatric Comorbidities in Patients with Epilepsy:A Cross-sectional Study
  IJAIMS
ORIGINAL ARTICLE
Psychiatric Comorbidities in Patients with Epilepsy:A Cross-sectional Study
1Saurabh Jaiswal, 2Santosh Kumar, 3Chandra S Sharma, 4Abhinav Kuchhal, 5Arpit Jaiswal
1,5Junior Resident (3rd Year), 2Associate Professor, 3Professorand Head, 4Senior Resident
1-5Department of Psychiatry, Rohilkhand Medical College &Hospital, Bareilly, Uttar Pradesh, India
Corresponding Author:
Santosh Kumar, Associate ProfessorDepartment of Psychiatry, Rohilkhand Medical College &Hospital, Bareilly, Uttar Pradesh, India,
Phone: +918126522510
e-mail: dr.santosh.kr@gmail.com
10.5005/jp-journals-10050-10068
 
ABSTRACT
Introduction: People with epilepsy are more likely than thegeneral population to have comorbid psychiatric disordersthat include anxiety, depression, and interictal and chronicpsychoses. Even though psychiatric comorbidity is common inepilepsy, it is underrecognized and undertreated, both in specialtyepilepsy centers and also in community-based services.A thorough assessment of this was sought in this study amongthe patients of Rohilkhand region of Uttar Pradesh (India).
Materials and methods: A total of 100 patients with epilepsywho visited the psychiatry outpatient clinic were recruitedfor this study. They were assessed in detail for the presenceof comorbid psychiatric disorders on Axis 1 with the help ofStructured Clinical Interview for Fourth Edition of the Diagnosticand Statistical Manual of Mental Disorders.
Results: Overall, it was found that a comorbidity of psychiatricdisorders was present in 45% of patients with epilepsy. Thefrequency of cooccurrence of different types of psychiatric disorderswas as follows: Mood disorders 21%, anxiety disorders14%, and psychotic disorders 28%.
Conclusion: Psychiatric comorbidities were found to be acommon problem in patients with epilepsy. The results of thisstudy are in line with many different research works both inIndia and abroad. A proper address of this issue is importantfor management, better outcome, and policy making in patientswith epilepsy.
Keywords: Axis 1 disorders, Comorbidity, Epilepsy, Psychiatric disorders.
How to cite this article: Jaiswal S, Kumar S, Sharma CS,Kuchhal A, Jaiswal A. Psychiatric Comorbidities in Patientswith Epilepsy: A Cross-sectional Study. Int J Adv Integ MedSci 2017;2(1):24-28.
Source of Support: Nil
Conflicts of Interest: None
 
 

INTRODUCTION

Epilepsy is a chronic disorder characterized by intermittent,stereotyped disturbance of consciousness, behavior,emotion, motor function, or sensation that on clinicalgrounds is believed to result from cortical neuronaldischarge.1 It is the second most common neurologicalcondition after headache.2 At least 50 million people inthe world suffer from recurrent nonprovoked seizures.The incidence (20-70 cases per 100,000/year), pointprevalence (5-10 cases per 1,000), and lifetime prevalence(2-5%) in industrialized countries2 emphasize its numericalimportance. The World Health Organization andthe International League against Epilepsy (ILAE) haveestimated that 34 million out of 50 million people withepilepsy live in developing countries.3 It is estimated thatin India, with a population of over 1.2 billion, there will bearound 6 to 10 million people with epilepsy, accountingfor nearly 1/5th of global burden.4

 
People with epilepsy are more likely than the generalpopulation to have comorbid psychiatric disorders thatinclude anxiety, depression, interictal and chronic psychoses,and aggression, with reported rates in chronicepilepsy ranging from 19 to 62%.5-7 In some instances,it has been possible to test the hypotheses that (1) psychiatricdisorder is associated with an increased risk fordeveloping the neurological disorder, and (2) the neurologicaldisorder is associated with an increased risk fordeveloping a new-onset psychiatric disorder.8 Epilepticactivity in the brain has an effect on the behavior, mood,and cognitive functions of the patient.9 It is importantfor clinicians to know which psychiatric disorders aremost likely to coexist with epilepsy so that they mayspecifically probe for these conditions when evaluatingthe patient.

Psychiatric symptoms can be classified accordingto their temporal relationship with seizure occurrence.They can be divided into peri-ictal (related to the seizureitself) and interictal (independent of the seizure) symptoms.Peri-ictal symptoms are symptoms that precede theseizure (preictal), clinical manifestations of the seizureitself (ictal), and symptoms that follow the seizuredirectly (postictal). Since the present study concernspsychiatric comorbidity in epilepsy, only the interictaldisorders are focused on.

MATERIALS AND METHODS

This was a hospital-based cross-sectional observationalstudy conducted at the Department of Psychiatry inRohilkhand Medical College & Hospital, Bareilly (UttarPradesh, India). With the help of purposive samplingtechnique, the patients with epilepsy who fulfilledthe inclusion and exclusion criteria of this study wereenrolled. Such patients came on their own with familymembers or were referred from other departments forfurther psychiatric evaluation. Diagnosis of epilepsy wasmade clinically using the guidelines on classificationof seizures, given by the ILAE, after which a thoroughphysical examination was done; neuroimaging andother relevant investigations were performed as andwhen required. The duration of this study was 1 year(September 2014 to August 2015). It was ensured that theadult (>18 years) patients diagnosed with epilepsy, in theinterictal period, were included in the study. The patientswho were physically unfit or who were not accompaniedwith at least one reliable informant were excluded fromthe study. Informed consent was taken and patients wereadministered following tools of assessment.

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Psychiatric Comorbidities in Patients with Epilepsy

Sociodemographic and Clinical Data Sheet
(Self-prepared)


This was specially prepared for noting down the social,demographic, and clinical variables of the patient, includingcase record number, age, sex, marital status, religion,education level, occupation, residence, socioeconomicstatus, type of family, type of seizures, etiology of seizure,age of onset of seizures, duration of epilepsy, seizurefrequency, family history of seizure, family history ofmental disorder, past history of mental disorder.

Structured Clinical Interview for DSM-IV

The Structured Clinical Interview for Fourth Edition ofthe Diagnostic and Statistical Manual of Mental Disorders(DSM-IV) Axis I disorders (SCID I)10 is a semi-structuredinterview for making the major DSM-IV Axis 1 diagnoses.The semi-structured interview covers all majorpsychiatric diagnoses, which meet diagnostic criteria asspecified in DSM-IV. Within each section, the diagnosisis assessed for the presence of the symptoms currently(i.e., within the last month) or in the patient's past. Forclinical research, patients are assessed using the SCID Iclinician-administered version, which is designed to beadministered by a clinician or a trained mental healthprofessional. During the course of interview, patientsare also asked subjectively whether they had ever beengiven a psychiatric diagnosis in the past.

Subsequently, the data thus collected were tabulatedand statistically analyzed using IBM Statistical Packagefor the Social Sciences version 21 for Window 8.1 withparametric and nonparametric tests being used asapplicable.

 
RESULTS

Table 1 shows the sociodemographic details of patientssuffering from epilepsy. The mean age of the patients was32.33 (±9.828) years and these patients were between 18and 60 years of age. The majority of them were Hindu(77%), of male gender (55%), educated from 1st to 10thstandard (53%), married (58%), and unskilled workers(52%) of middle social economic status (71%), nuclearfamily type (64%), and urban (44%) background of UttarPradesh state of India (88%).

Table 2 shows clinical details of patients with epilepsy.Mean age of onset of seizures was 21.33 ± 8.58 years, whilethe mean total duration of epilepsy was 5.72 ± 4.01 years.In the current study, 45% of the patients were found to besuffering from complex partial seizure, while 35% hadgeneralized tonic-clonic seizure, and 17% had secondarygeneralization; only 3% patients presented with simplepartial seizure in our study. The etiology of majority (56%)seizure was idiopathic followed by infections (33%) andothers, such as vascular (5%), traumatic (4%), and tumor(2%). The frequency of seizure was one or less than oneper month in 21% patients, 2 to 4 seizures per month in29% patients, 5 to 15 seizures per month in 25% patients,16 to 30 seizures per month in 17% patients, and morethan 30 per month in 8% of the patients. Family historyof seizure in first- or second-degree relative was found in23% of the patients, while 77% did not have any familyhistory. Family history of some mental disorders wasfound in 25% of the patients, while 75% of the patientsdid not have such family history. Past history of mentaldisorder was found in 13% of the patients, while 87%of the patients had no past history of mental disorders.

Table 1: Sociodemographic details of the patients sufferingfrom epilepsy (n = 100)
Psychiatric Comorbidities in Patients with Epilepsy: A Cross-sectional Study
SD: Standard deviation

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Table 2: Clinical details of patients with epilepsy (n = 100)
Psychiatric Comorbidities in Patients with Epilepsy: A Cross-sectional Study

Graph 1 shows gross distribution of psychiatricdisorders in patients with epilepsy. Table 3 shows thedetailed distribution of comorbid psychiatric disorders asper SCID I in the patients with epilepsy. Overall, the frequencyof occurrence of different psychiatric conditionswas as follows: Mood disorder - 21%, anxiety disorder -14%, psychotic disorder - 28%, and other diagnosis - 11%.Mood disorders were further classified into major depressivedisorder recurrent in full remission - 8%, majordepressive disorder recurrent ongoing - 2%, depressivedisorder due to a general medical condition (GMC) - 5%,depressive disorder not otherwise specified (NOS) - 3%,dysthymia - 2%, major depressive disorder single episode- 1%. Anxiety disorders were further classified into panicdisorder without agoraphobia - 4%, agoraphobia withoutpanic disorder - 2%, social phobia - 2%, conversion disorder- 2%, specific phobia - 1%, obsessive compulsivedisorder - 1%, posttraumatic stress disorder (PTSD) - 1%,generalized anxiety disorder - 1%. Psychotic disorderswere further classified into schizophrenia - 2%, briefpsychotic disorder - 2%, psychotic disorder due to GMCwith delusions - 5%, psychotic disorder due to GMC withhallucinations - 14%, psychotic disorder NOS - 5%. Otherdisorders diagnosed were: Alcohol abuse/dependence -8%, benzodiazepine dependence - 1%, opiate dependence- 1%, cannabis abuse - 1%.

 
Psychiatric Comorbidities in Patients with Epilepsy: A Cross-sectional Study
Graph 1: Distribution of psychiatric comorbidities in patientswith epilepsy on SCID I

Table 3: Distribution of psychiatric comorbidities in patients withepilepsy (n = 100) on SCID I
Psychiatric Comorbidities in Patients with Epilepsy: A Cross-sectional Study

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Psychiatric Comorbidities in Patients with Epilepsy

DISCUSSION

This was a hospital-based cross-sectional observationalstudy to look into details of comorbid psychiatric disordersin patients with epilepsy. While including thepatients in our study, it was ensured they were not in ictalor postictal phase of the epilepsy, as it would have biasedthe prevalence of psychiatric diagnosis, since during thepostictal phase symptoms that resemble psychosis arecommonly seen in the patients, which would have thengiven high false-positive rates of psychosis. Therefore,to enroll the patients for this study, purposive samplingtechnique was used.

In this study, 45% of participants with epilepsy had apsychiatric diagnosis. Other important studies from Indiaand abroad of epilepsy patients have estimated the ratesof overall psychiatric morbidity between 23 and 68%.11,12Smaller studies consistently show higher rates of psychopathologyin epilepsy, although there is also evidenceindicating that psychiatric illness continues to remainunderdiagnosed and undertreated in patients withepilepsy.13 Studies examining the relationship betweenpsychopathology and epilepsy to date have tended to besmall, use a nonrepresentative sample, and have failedto use standardized instruments. The high rate of psychiatricdiagnosis in this study, therefore, may be dueto the use of standardized diagnostic instrument, thusidentifying more cases. The findings of the current studyare very similar to those of Pintor et al14 who found that45.7% of patients in a tertiary referral center had a SCID Idiagnosis. A similar hospital-based cross-sectional studydone in North-east India, in which patients with epilepsywere evaluated with Mini International NeuropsychiatricInterview, showed psychiatric comorbidity in 50%.15Another study conducted at an urban referral hospital incentral India by Saha16 in which a control group was alsoincluded and the diagnostic tool used was Schedules forClinical Assessment in Neuropsychiatry, the prevalencerate of psychiatric disorders in epilepsy was found tobe 44%. In another similar study conducted in SouthIndia by Kandeeban et al,17 which also included controlgroups, the prevalence rate of psychiatric disorders wasfound to be 45%. There are several other studies whichshow similar prevalence rates of psychiatric disorders inepilepsy, such as 58% by Adams et al,18 41% by Gaitatziset al,7 and 37% by Davies et al.19

 
Fourteen percent of patients were diagnosed withan anxiety disorder, the most common diagnosis beingpanic disorder without agoraphobia. In this study, theoverall anxiety findings were found to be lower comparedwith previous published rates of anxiety disorders inlarge population using SCIDs: 18.4,20 21.5,14 and 52.1.21Whereas many patients with epilepsy experience anxietyor panic-type symptoms preictally or as part of an aura,the use of the SCID identifies those with true panicdisorder, i.e., panic symptoms occurring unexpectedlyand not due to the direct physiological effect of a GMC.The use of a SCID I diagnostic interview therefore, mostlikely accounts for this study, identifying a percentageof participants with anxiety disorders being at the lowerrange of the published figures. We found no evidencethat higher seizure frequency predicted an increasedlikelihood of an SCID diagnosis being made. However,the relatively small number of patients involved in thestudy may have influenced this.

CONCLUSION

In this study, overall, it was found that a comorbidityof psychiatric disorders was present in 45% of patientswith epilepsy. The frequency of cooccurrence of differenttypes of psychiatric disorders was as follows:Mood disorders - 21%, anxiety disorders - 14%, andpsychotic disorders - 28%. In mood disorders, majordepressive disorder recurrent in full remission was theprincipal diagnosis (8%), in anxiety disorders, panicdisorder without agoraphobia was the main diagnosis(4%), and in psychotic disorders psychotic disorderdue to GMC with hallucinations was the most commondisorder (14%). The results of this study are in line withmany different research works, both in India and abroad.It further emphasizes that healthcare providers need torecognize the burning issue of different aspects of psychiatriccomorbidity for management, better outcome,and policy making in patients with epilepsy. This studywas a cross-sectional study in which only patients withepilepsy in the interictal state were enrolled and also nocontrol group was used. To overcome these limitations,it is being recommended that further research on thistopic should include a larger sample size, inclusion ofcontrol group, and a prospective study design.

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